Dr. Mohammad Walidur RahmanDr Pritam Kumar

Resident , Phase A (Cardiology)

Patient Information

Name Ms X

Sex Female

Age 24 years

Address G

Date of admission 27-10-2013

Presenting complaints

Progressive swelling in the neck- 4 yrs

Drooping of both eyelids- 2 yrs

Presenting complaints

Swelling in the neckNoticed four years backProgressiveAssociated with

○ Heat intolerance○ Weight loss○ Excessive sweating○ Hyperdefecation○ irritability

Bulging of both eyeballs6 months after initial symptomsAssociated with

○ redness ○ retro-orbital pain ○ increased lacrimation ○ double vision

Drooping of both eyelidsFor 2 years, more marked for last 7 monthsDiurnal variationInability to move the eye in all directions

H/O occasional swallowing difficulty, nasal regurgitation

No history of slurring of voice

No history suggestive of RA , SLE , DM or Addisons disease

Past history: Nothing significant

Family history : No history of such illness or any autoimmune disorder

General Examination

Bilateral partial ptosis Diffusely enlarged thyroid

FirmNon tenderSmooth surfaceWithout retrosternal extensionThyroid bruit : absent

General Examination

Pulse : 72 beat/min BP : 120/80 mmhg Temp : 98 F Resp rate : 16 breath/min

Neurological examination

Bilateral partial ptosis Bilateral mild proptosis (Rt>lt)

Neurological examination: cont… Visual acuity: 6/9 on both eyes External ophthalmoplegia Intact Light reflex Fundus : Normal

Motor system : Reflexes are normal Sensory system : Normal

Investigations Test Name 21/09/2013

Hb 13.2 gm/dl

ESR 20 mm in1st hr

RBC 5X1012/L

Platelets 400X109/L

WBC 9.5X109/L

Neutrophil 69%

Lymphocytes

25%

Monocytes 04%

Eosinophils 02%

basophils 00%

27-07-11

19-05-13

18-08-13

18-09-13

26-10-13

28-10-13

s. TSH <0.05 microIU/ml

<0.01 microIU/ml

0.03 microIU/ml

0.018 microIU/ml

0.012 microIU/ml

S. FT3 7.03 ng/ml

30 pg/ml

14.5 pg/ml

3.10 pg/ml

S. FT4 >30 microgm/dl

60.64 Pmol/ l

5.10 ng/dl

1.85 ng/dl

1.15 ng/dl

19-05-13Anti TPO Ab : 637.78 iu/mlAnti TG Ab : >1000 iu/ml

25-05-13USG of thyroid : thyroid gland is markedly

enlarged in size(both lobes) with uniform echotexture

21-05-13

Tc 99 Scintigraphy : both lobes of thyroid gland is markedly enlarged in size with intensity increased & uniform radiotracer conc. Background activity is not seen

01-06-13RNS Test : pre & post exercise RNS

showed significant (>15%) decrease of CMAP in orbicularis oculi (lt)

02-06-13Anti ach-R Ab : 15.5 nmol/l

06-06-13HRCT of Chest : Enlarged thymus

Investigations 28/05/13 28/10/2013

FPG2h ABF

4.4 mmol/L7.7 mmol/l

Serum Creatinine

0.4 mg/dl 0.6 mg/dl

Serum Albumin 36 gm/l

SGPT 47 U/L 50 U/L

Na 148 mmol/l 144 mmol/l

K 3.8 mmol/l 4.4 mmol/l

Cl 106 mmol/l 108 mmol/l

Calcium 9.1 mg/dl

RBS 4.4 mmol/l

24-06-13CT scan of brain & orbit : normal

29-10-13ECG : Within normal limitChest X – Ray : normal

Diagnosis

Graves’ thyrotoxicosis with ophthalmopathy

Myasthenia Gravis

Disease course

Medication : Carbimazole 30 mg/day ( 22/05/13 – 27/

5/13)20 mg/day ( 27/ 5/13 – 20/8/13)45 mg/day (20/8/13 – till now)Propranolol 20 mg/day Pyridostigmine 30mg BD (S.F 01/06/13)

Symptoms of toxicosis resolved within 2-3 wks

Symptoms of myasthenia improved initially

But later on she experienced worsening of ptosis & dysphagia

On 24/09/13 she became restless which was associated with dyspnea & dysphagia

It was preceded by cough & fever Got admitted into DMCH Treated as Myasthenic crisis

High flow oxygenIV CeftriaxoneIV dexamethasone

Now she is waiting for Thymectomy

Diagnosis

Graves’ thyrotoxicosis with ophthalmopathy

Myasthenia Gravis with H/O Myasthenic crisis

Problem list

How to prepare the patient for Thymectomy?

Role of steroid ?

Is beta blocker a contributor for poor respone of Myasthenia?

THANK YOU